Healthcare professional’s guide to Cardio-Pulmonary ... · Dr Sathish Kumar Parasuraman, MRCP...

1

Healthcare professional’s guide to Cardio-Pulmonary Exercise Testing

Sathish Parasuraman1; Konstantin Schwarz2; Nicholas D Gollop1; Brodie Loudon1; Michael P.

Frenneaux1

1University of East Anglia; 2 University Hospital Birmingham

Dr Sathish Kumar Parasuraman, MRCP (Corresponding Author)

BHF Cardiology Research Fellow

2.21d, Bob-Champion Research and Education Building

James Watson Road

University of East Anglia

Norwich Research Park

Norwich NR4 7UQ

Ph. 01603 591793

Email: [email protected]

Dr Konstantin Schwarz, MRCP

Cardiology Registrar

University Hospital Birmingham

Birmingham

B15 2TH


Dr Nicholas D Gollop, MB BCh

MRC Doctoral Research Fellow in Cardiology



Norwich NR4 7UQ


Dr Brodie L Loudon, MBBS

MRC Doctoral Research Fellow in Cardiology



Norwich NR4 7UQ


Prof Michael P. Frenneaux, MD, FRCP, FRACP, FACC, FESC

Head of Norwich Medical School

Bob Champion Research and Education Building

James Watson Road



Norwich NR4 7UQ

Tel: 01603 592376


2

Abstract

Cardiopulmonary exercise testing (CPEX) is a valuable clinical tool that has proven indications

within the fields of cardiovascular, respiratory and pre-operative medical care. Validated uses

include investigation of the underlying mechanism in patients with breathlessness, monitoring

functional status in patients with known cardiovascular disease and pre-operative functional

state assessment. An understanding of the underlying physiology of exercise, and the

perturbations associated with pathological states, is essential for healthcare professionals to

provide optimal patient care. Healthcare professionals may find performing CPEX to be

daunting, yet this is often due to a lack of local expertise and guidance with testing. We outline

the indications for CPEX within the clinical setting, present a typical protocol that is easy to

implement, explain the key underlying physiological changes assessed by CPEX, and review

the evidence behind its use in routine clinical practice. There is mounting evidence for the use

of CPEX clinically, and an ever-growing utilisation of the test within research fields; a sound

knowledge of CPEX is essential for healthcare professionals involved in routine patient care.

Keywords: cardio-pulmonary exercise testing; CPEX; exercise testing; CPEX evidence; guide

to CPEX; guide to exercise testing; understanding CPEX; CPEX supervision; CPEX training;

basic CPEX; CPEX indications.

Key messages:

1. CPEX provides valuable insight into pathophysiology of a breathless patient.

2. CPEX is a safe test and increasingly performed on high risk patients.

3. There is strong evidence for CPEX data in monitoring heart failure patients and

predicting peri-operative risk in lung and abdominal surgery.

4. Knowledge of CPEX is essential for the healthcare professional, with mounting

evidence in the field.

3

Introduction

Cardio-pulmonary exercise (CPEX) testing is used to establish the degree of exercise

limitation, to identify the underlying mechanisms responsible in patients with breathlessness,

and to monitor functional status in cardiovascular disease (1). It is an important prognostic tool

and decision-aid in the assessment of perioperative risk (2). In addition to the routine

parameters measured during the exercise electrocardiogram (ECG) stress test, CPEX can

provide measurements of oxygen (O2) consumption, carbon dioxide (CO2) production, and

lung ventilation to provide valuable information about respiratory, cardiovascular and muscle

metabolic function as well as the subject’s effort during the test. Despite its useful diagnostic

and prognostic functions, and established role in several guidelines for management of

cardiovascular diseases, CPEX has remained largely a research or sport sciences tool, and is

grossly under-utilized in clinical practice. This is commonly due to a lack of local expertise or

awareness about the utility of CPEX among physicians. We review the indications and

contraindications for CPEX and describe a standard protocol for cardiopulmonary stress

testing. Additionally, we propose a practical reporting and data interpretation guide for the

junior cardiology/respiratory trainee.

Indications and contraindications of CPEX

The diagnostic and prognostic indications, along with the contraindications for CPEX testing

are listed in Table 1. The ATS/ACCP guidelines (2003) include these absolute

contraindications to CPEX (3), however recently the test has been performed safely in

conditions like severe aortic stenosis (4). Indications to perform the test are also increasing, as

in the diagnosis of heart failure with normal ejection fraction (5) and in exercise prescription

for heart failure patients (6).

4

Table 1: Indications and contraindications of cardio-pulmonary exercise testing

Indications

Diagnostic Breathlessness of unknown cause

Cardiac ischemia detection

Prognostic

Heart failure (prioritization for heart transplantation)

Perioperative risk in patients undergoing major surgery

Chronic obstructive pulmonary disease (COPD)

Pulmonary hypertension

Risk of lung resection

Congenital heart disease

Absolute Contraindications Acute myocardial infarction (3-5 days)

Acute myocarditis

Severe symptomatic aortic stenosis

Uncontrolled heart failure

Uncontrolled arrhythmia

Dissecting aneurysm

Resting Oxygen saturation of <86%

Preparation for CPEX Assessment

Patients are advised to avoid caffeine, nicotine and food for two hours prior to CPEX (7).

Enquiry into the patient’s past medical history, medications, any limitations and any special

requirements for participation in CPEX should be made. If the patient has a pacemaker,

defibrillator or a cardiac resynchronisation device, guidance of the cardiac physiologist or

rhythm management specialist should be sought. Additional assessments which should be

completed in advance of CPEX include: clinical examination of the cardiovascular, respiratory

and peripheral vascular systems, ECG, resting oxygen saturation, blood pressure (BP),

spirometry, including vital capacity and forced expiratory volume in the first second

(FEV1).Commonly used abbreviations in CPEX are given in table 2.

5

Table 2: Commonly used abbreviations in CPEX (8)

VO2 (oxygen uptake)

Amount of oxygen extracted from inspired

gas per unit time

(may be expressed as an absolute value

(ml/min) or corrected for weight (ml/kg/min))

VCO2 Amount of carbon dioxide exhaled from the

body per unit time (usually, per minute)

VO2 max

Maximum oxygen uptake achievable

(confirmed by repeated tests), despite further

work rate increases

Peak VO2

Highest VO2 achieved during presumed

maximal effort (as indicated by RER>1.15),

for that test

R (or Respiratory Exchange Ratio) Ratio of carbon dioxide output to oxygen

uptake (VCO2/VO2)

VE Volume of air inhaled or exhaled by the body

in 1 minute

MVV (Maximum Voluntary Ventilation) The maximum potential ventilation achievable

(estimated as FEV1X40)

Anaerobic threshold (AT)

Exercise limit above which the subject’s

anaerobic high energy phosphate production

supplements aerobic metabolism

Breathing Reserve

The difference between maximum voluntary

ventilation and the achieved maximum

exercise minute ventilation

Checklist before the test

Clinical history

Drug history

Device history (pacemakers/defibrillators)

Clinical examination

Electrocardiogram

Blood pressure

Oxygen saturation

Recent haemoglobin

6

Protocol

The patient is prepared by connecting them to an ECG monitor and facemask. The facemask

is tested for any air-leak and connected to the gas analyser. An alternative to facemask is

mouthpiece with a nose-clip. Saliva dribbling from the mouthpiece is however a problem

especially at peak exercise. A pulse oximeter and sphygmomanometer are attached. Oxygen

saturation could be measured either through a finger or earlobe probe (3). New forehead sensors

are another alternative.

Incremental exercise testing can either be performed on a treadmill or an electronically-braked

cycle. Treadmills are widely used in USA and UK (9), and are a popular method allowing

most patients to exercise to their maximal physical limit, achieving satisfactory end-points.

Cycle ergometers are advantageous for quantifying work-rate accurately and additionally

enable clinicians to gain arterial blood gas (ABG) samples if necessary. People with

musculoskeletal limitations or imbalance that might limit weight-bearing may prefer the cycle

ergometer, however hamstring fatigue could stop cycle exercise before true peak VO2 is

reached (9). The peak VO2 achieved on cycle is usually 10-20% lower than that on a treadmill

(9). Figure 1 shows a patient performing CPEX on a cycle ergometer.

7

Figure 1: CPEX test performed on a cycle ergometer

1. ECG monitor

2. Gas exchange monitor

3. Saturations probe

4. Oxygen and carbon dioxide sampler

Current software calculates the maximum watts achievable automatically, based on the

patient’s sex, age, height, and weight. Then a protocol is selected to reach the maximum

exercise in 10-minutes, usually by dividing likely maximum watts by 10. The patient should

be encouraged to exercise to his/her maximum physical limit, so that O2 consumption at peak

exercise can be measured.

Several protocols with different increments in workload exist; a typical example is presented

in Table 3. Following a 2-minute warm-up period, the exercise starts with speed and gradient

increased by 1 km/hour and 1% respectively every minute. Less fit patients can use a protocol

with half a kilometre speed increase every minute. The operator records the reason for stopping

the test at the end.

8

Table 3: Example of a typical treadmill CPEX protocol

Warm-

up

2 mins

Stage 1

1 min

Stage 2

1 min

Stage 3

1 min

Stage 4

1 min

Stage 5

1 min

Stage 6

1 min

Stage 7

1 min

Stage 8

1 min

Stage 9

1 min

Speed

Kilometre/hour 2 1 2 3 4 5 6 7 8 3

Gradient 0% 1% 2% 3% 4% 5% 6% 7% 8% 0%

Patients should be monitored closely for complications. Table 4 lists the indications for

terminating the test early.

Table 4 : Indications for terminating a CPEX test (3)

Symptoms and signs

Limiting chest pain

Dizziness

Poor co-ordination

Sudden pallor

Confusion

Measurements

Significant ECG changes suggesting ischemia (ST depression >3 mm, ST elevation, LBBB)

Second or third degree heart block

Ventricular tachycardia

Supraventricular tachycardia, new onset atrial fibrillation

Fall in systolic blood pressure of >20 mmHg

Severe desaturation to <80%

Physiological parameters

Anaerobic threshold

Oxygen (O2) consumption and carbon dioxide (CO2) production increase with incremental

workload on exercise. CO2 production is linearly related to the amount of O2 consumed during

exercise, until the onset of anaerobic metabolism (3). The lactate produced by anaerobic

metabolism contributes to additional CO2 production, measured in the expired air from this

time point, resulting in a disproportionate increase in CO2. This inflection point between the

linear component and the progressively greater increase in CO2 production relative to the O2

consumption is called the anaerobic threshold (10). An example is shown in figure 3.

9

Peak and Max VO2

O2 consumption obtained at peak exercise (averaged over 60 seconds) is called peak VO2

(PVO2). A peak VO2 <85% of that predicted for age and gender, indicates significant exercise

limitation (3). Normal age and sex specific values for Peak VO2 have been defined in various

studies (11, 12). At maximal exercise, the VO2 consumption plateaus despite incremental

increases in workload. This state is achievable in healthy adults (13). Max VO2 is a term used

to denote the maximum O2 consumption possible for that subject, and is measured by several

constant-work-rate exercise tests, each at varying workloads. Peak VO2 achieved in

incremental testing is usually very close to the Max VO2. Max VO2 is not routinely used in

the clinical setting.

Maximum Voluntary Ventilation (MVV)

Maximum Voluntary Ventilation (MVV) is estimated from pre-test FEV1 obtained by

spirometry and multiplied by maximum respiratory rate (MVV = FEV1X40). Breathing reserve

is then calculated by subtracting the ventilatory equivalent, (VE, expressed in litres/minute)

measured at peak exercise from the MVV (BR= MVV-peak VE [normal >11 litres]). Breathing

reserve is preserved in patients with cardiac limitation and in those with deconditioning, but is

usually reduced to <11L in patients with respiratory disease (14).

Lung Dead Space

The ratio of the lung dead space (VD) to the tidal volume (VT) is another important

measurement. The VD/VT is increased in patients with obstructive or restrictive lung diseases

and in pulmonary vascular disease (15-17). VD/VT can be calculated by the formula:

VD/VT= (PaCO2-PECO2)/PaCO2

[PaCO2-partial pressure of arterial CO2 (blood gas measurement); PECO2-patial pressure of CO2 in

expired air (CPEX measurement) (18)]

10

Ventilation-Perfusion mismatch

Arterial Blood Gas measurements can provide valuable additional information. The difference

between alveolar and arterial O2 levels [P(A-a)O2] is usually between 20-30 mm Hg and this

does not increase during exercise in normal subjects. In patients with lung disease or pulmonary

vascular disease the difference is exaggerated during exercise due to ventilation-perfusion

(V/Q) mismatch. Additionally, the difference between arterial and end-tidal CO2 levels [P(a-

ET)CO2] remains positive throughout exercise in patients with lung disease, again due to V/Q

mismatch (18).

When ventilation (VE on Y axis) is plotted against carbon dioxide (VCO2 on the X axis), the

relationship is linear until the anaerobic threshold is reached, with a slope of 23-28 degrees.

The relationship is steeper in conditions associated with increased VD/VT ratio such as heart

failure, pulmonary vascular disease, interstitial lung disease and COPD, while it is normal in

patients with exercise limitation due to deconditioning (3,19). The slope is measured from the

beginning of exercise to just after the anaerobic threshold, as shown in figure 2. The VE/VCO2

slope increases with age in normal subjects. A value of <30 degrees is considered normal.

Figure 2: VE/VCO2 slope measurement-The slope is measured from the beginning to just after the

anaerobic threshold. (AT-anaerobic Threshold, VE-ventilation per minute, VCO2- CO2 produced per

minute)

11

Analysis and interpretation

A peak VO2 of <85% predicted (for age and gender) indicates significant exercise limitation

(3).

Respiratory Exchange ratio

Respiratory Exchange Ratio (RER or simply R) is the ratio of the CO2 production to O2

consumption (RER=VCO2/VO2). Once anaerobic metabolism begins, RER progressively

increases. A RER of >1.15 at peak exercise indicates an adequate exercise test (3). Current

software measures RER automatically and is displayed throughout the test.

Anaerobic threshold measurement

Anaerobic threshold can be identified from several scatter graphs obtained by automatic

software by plotting gas exchange markers against each other. The V-slope method, where the

VCO2 is plotted against VO2 is the preferred method (see Figure 3). Other graphs used for

determining the anaerobic threshold are VO2, VCO2 against time (see Figure 4), VE/VCO2,

VE/VO2 against time, and PETCO2, PETO2 against time.

Figure 3: V-slope method for detecting anaerobic threshold – NB: this is independent of the subject’s ventilatory

response. (AT-Anaerobic Threshold)

12

Figure 4: Another method for detecting anaerobic threshold. VO2 and VCO2 plotted against time

Heart disease

Oxygen consumption per heart rate (HR) (termed “oxygen pulse”) can be calculated by

dividing the Oxygen consumption by HR, and this rises steadily throughout exercise. A fall of

oxygen pulse with increasing workload indicates a fall in cardiac output (Figure 5). A normal

breathing reserve, low VO2 at anaerobic threshold (VO2 at anaerobic threshold (AT) of <40%

of predicted Peak VO2)), flattening oxygen pulse, and high VE/VCO2 slope indicate to a

cardiac pathology (3). Flattening of the O2 pulse in a person with normal left ventricular

function and spirometry could suggest myocardial ischemia, and this precedes ECG changes

(20).

Figure 5: Oxygen pulse in different subjects

A- Healthy volunteer. VO2 pulse increases steadily with work rate

B- Myocardial ischemia. Late flattening at high workload caused by myocardial dyskinesia

C- Dilated cardiomyopathy. Early flattening of VO2 pulse

13

Patients with a patent foramen ovale (PFO) may develop a right-to-left cardiac shunt during

exercise, when the right atrial pressure exceeds that of the left atrium due to functional

pulmonary hypertension (21). This may cause an abrupt decrease in the partial pressure of the

exhaled CO2 (PETCO2), with simultaneous abrupt increases in VE/VCO2, VE/VO2 (due to

increase in minute ventilation, VE) and a drop in arterial O2 saturation (21).

Lung disease

An abnormal spirometry, high VD/VT, desaturation during exercise, low breathing reserve,

and increase in alveolar-arterial O2 gradient [(A-a)O2] indicate respiratory pathology (3).

Normal individuals exhaust their cardiovascular potential at peak exercise. Their breathing

reserve is preserved (>11L) at peak exercise, indicating that the limitation to further exercise

is the cardiovascular system (3). One exception to this are athletes who have excellent

cardiovascular fitness; they can deplete their breathing reserve at peak exercise to <11 L, but

achieve a supra-normal peak VO2 (22).

Deconditioning

A low peak VO2, normal VE/VCO2 slope, normal VO2 at anaerobic threshold, and preserved

breathing reserve indicate deconditioning (3). A simplified diagnostic approach is shown in

Figure 6.

14

Figure 6: Simplified diagnostic flowchart

Evidence base

Heart Failure

CPEX is a cornerstone test in identifying heart failure patients for heart transplantation; a peak

VO2<14 mL/kg/min in patients not on beta-blockers and peak VO2<12 mL/kg/min in patients

on beta-blockers is the current recommendation for consideration for heart transplantation (23-

25).

VE/VCO2 slope is another predictor of mortality in heart failure patients. Gitt et al showed a

low VO2 at anaerobic threshold (AT) of <11 mL/kg/min and a high VE/VCO2 slope of >34

degrees at AT were strong predictors of 6 month prognosis in heart failure patients (26).

However, the VE/VCO2 slope is yet to find a place in cardiac transplant guidelines.

Lung resection

In the case of lung tumour resection surgery, Beckles’ et al review of the literature (27) showed

lung cancer patients with:

15

1. Peak VO2 of >20 were not at increased risk of complications

2. Peak VO2 of <15 were at increased risk of post-operative complications

3. Peak VO2 of <10 were at very high risk of peri-operative complications

CPEX is not necessary in all patients undergoing lung resection, but to risk-stratify patients

with an FEV1 or diffusion capacity <80% of predicted on pre-operative testing (28).

Abdominal surgery

CPEX is increasingly used for risk stratification in patients with known cardiovascular and

respiratory disease being considered for major non-cardiac surgery. Current evidence is:

1. VO2 at AT of >11 mL/kg/min combined with a VE/VCO2 slope of <35 are predictors for

low cardio-vascular risk after major abdominal surgery (29, 30).

2. A VO2 at AT of >11 mL/kg/min is correlated with improved post-operative survival in open

and endo-vascular aortic surgery (31). Nagamatsu et al showed that in patients undergoing

oesophagectomy, a low peak VO2 was associated with increased cardiovascular complications

(32). They concluded that a peak VO2 of <800 ml/m2 is associated with a higher risk.

Reporting

A standard reporting format includes pre-test observations, test findings and interpretation. An

example is given below. In our department, an experienced cardiologist reports all CPEX’s.

An accurate interpretation of the test should be made available within 72 hours; this ought to

be earlier if the findings are significantly abnormal (33). A sample reporting tool is shown in

table 5.

16

Table 5: Sample reporting tool for cardio-pulmonary exercise test

Name

Age

DOB

Hospital ID

Height

Weight

BMI

Ideal body weight

Haemoglobin

Smoking status

Spirometry:

FEV1

FVC

FEV1/FVC

KCO

MVV

Exercise test details:

Protocol

Duration of exercise

Reason for stopping the test

Resting heart rate Peak Heart Rate

Resting blood pressure Peak blood pressure

Resting Oxygen saturation Peak Oxygen Saturation

Exercise test findings:

Peak Respiratory Exchange Ratio (RER)

Predicted Peak VO2

Peak VO2

Peak VO2/ Predicted peak VO2 %

VO2 at Anaerobic Threshold

Peak Ventilation (VE)

Breathing reserve

VE/VCO2 slope

Oxygen Pulse (VO2/heart rate) at peak exercise

ΔVO2/Work rate

VD/VT (if blood gas measured)

PETCO2 at Rest Peak Exercise

Peak PETCO2

ECG changes

Interpretation

17

Supervision and monitoring

The risk of acute myocardial infarction (AMI) during an exercise test is 1 in 2500 and risk of

death is 1 in 10000 cases (34). The physician in-charge of the exercise laboratory decides on

the appropriateness of the request for testing, and the degree of supervision needed depending

on the specific clinical situation. In patients who have had a recent AMI (7-10 days), severe

valvular stenosis, or complex arrhythmias, direct physician supervision is indicated (35). In

most other cases appropriately trained physiologists and specialist nurses can conduct the test

safely, with the physician in the immediate vicinity. Two people are required to conduct the

test, both qualified in cardio-pulmonary resuscitation (36). Blood pressure should be measured

every 2-3 minutes and more frequently in high risk patients (13). Continuous ECG monitoring

is mandatory during the test and should be continued 6 minutes into recovery (13).Manual

measurement of blood pressure is still the preferred method during stress test (34). Staff

performing the test should be aware of the indications for exercise test and be able to recognise

adverse events (13).

The AHA guidelines (2000) recommend that a physician in-charge should have participated in

50 procedures over a dedicated 4 week period to achieve competence in supervision and

reporting of exercise tests, and should continue to perform 25 cases per year to preserve

competence (35). The physician is responsible for data interpretation and suggesting further

evaluation and testing (33). The physician should also maintain advanced cardiovascular life

support competence. The AHA guidelines detail the cognitive skills required for performing

and interpreting the test (35).

The exercise laboratory should be a spacious room and have the necessary equipment for

advanced cardiac life support. Each laboratory should have a written emergency plan and all

18

personnel should rehearse it on a regular basis (36). Written informed consent is required prior

to the exercise test (9).

Conclusion

CPEX testing is a relatively safe non-invasive tool which provides excellent diagnostic and

prognostic information in patients with heart or lung disease. It should be utilized as a

complementary diagnostic tool in the investigation of breathless patients, along with chest X-

ray, echocardiography, pulmonary angiography, right heart catheterisation, and coronary

angiography.

It is increasingly used in pre-operative risk assessment, cardiac and pulmonary rehabilitation,

and adult congenital heart disease. With increasing applications and understanding, a sound

grasp of the nuances of CPEX testing is mandatory for the cardiac, pulmonary and general

physician.

19

References

(1) Weber KT, Janicki JS. Cardiopulmonary exercise testing for evaluation of chronic cardiac failure. Am J Cardiol 1985;55(2):22A-31A.

(2) Bolliger CT, Jordan P, Soler M, Stulz P, Gradel E, Skarvan K, et al. Exercise capacity as a predictor of postoperative complications in lung resection candidates. American Journal of Respiratory and Critical Care Medicine 1995;151(5):1472-1480.

(3) ATS/ACCP Statement on Cardiopulmonary Exercise Testing. American Journal of Respiratory and Critical Care Medicine 2003;Vol. 167(No. 2):211-277.

(4) Levy F, Fayad N, Jeu A, Choquet D, Szymanski C, Malaquin D, et al. The value of cardiopulmonary exercise testing in individuals with apparently asymptomatic severe aortic stenosis: A pilot study. Archives of Cardiovascular Diseases 2014 10;107(10):519-528.

(5) Mahadevan G, Dwivedi G, Williams L, Steeds RP, Frenneaux M. Epidemiology and diagnosis of heart failure with preserved left ventricular ejection fraction: Rationale and design of the study. European Journal of Heart Failure 2012;14(1):106-112.

(6) Mezzani A, Agostoni P, Cohen-Solal A, Corrà U, Jegier A, Kouidi E, et al. Standards for the use of cardiopulmonary exercise testing for the functional evaluation of cardiac patients: A report from the exercise physiology section of the European association for cardiovascular prevention and rehabilitation. European Journal of Cardiovascular Prevention and Rehabilitation 2009;16(3):249-267.

(7) Chapter3:Pre-Exercise evaluation. In: Pescatello L, Arena R, Riebe D, Thompson P, editors. ACSM’s Guidelines for Exercise Testing and Prescription 9th Ed. 2014. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2014. p. 39-58.

(8) Wasserman K, Hansen J, Darryl Y. Sue, William Stringer, Kathy E. Sietsema, Xing-Guo Sun, et al. Symbols and Abrreviations. ; 2012. p. 542-544.

(9) Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, Bittner VA, et al. Exercise standards for testing and training: A scientific statement from the American heart association. Circulation 2013;128(8):873-934.

(10) Beaver WL, Wasserman K, Whipp BJ. A new method for detecting anaerobic threshold by gas exchange. J Appl Physiol 1986 American Physiological Society;60(6):2020-2027.

(11) Wasserman K, Hansen J, Sue D, Stringer W, Sietsema K, Sun X, et al. NORMAL VALUES. . 5th ed. PHILADELPHIA: LIPPINCOTT WILLIAMS & WILKINS; 2012. p. 155.

(12) Gargiulo P, Olla S, Boiti C, Contini M, Perrone-Filardi P, Agostoni P. Predicted values of exercise capacity in heart failure: Where we are, where to go. Heart Fail Rev 2014;19(5):645-653.

20

(13) Balady GJ, Arena R, Sietsema K, Myers J, Coke L, Fletcher GF, et al. Clinician's guide to cardiopulmonary exercise testing in adults: A scientific statement from the American heart association. Circulation 2010;122(2):191-225.

(14) Hansen JE, Sue DY, Wasserman K. Predicted values for clinical exercise testing. Am Rev Respir Dis 1984;129(2 SUPPL.):S49-S55.

(15) Martinez FJ, Stanopoulos I, Acero R, Becker FS, Pickering R, Beamis JF. GRaded comprehensive cardiopulmonary exercise testing in the evaluation of dyspnea unexplained by routine evaluation. Chest 1994 January 1;105(1):168-174.

(16) Elbehairy AF, Ciavaglia CE, Webb KA, Guenette JA, Jensen D, Mourad SM, et al. Pulmonary Gas Exchange Abnormalities in Mild Chronic Obstructive Pulmonary Disease. Implications for Dyspnea and Exercise Intolerance. Am J Respir Crit Care Med 2015 Jun 15;191(12):1384-1394.

(17) Miller A. Pulmonary Function in Asbestosis and Asbestos-Related Pleural Disease. Environ Res 1993 4;61(1):1-18.

(18) Wasserman K, Hansen J, Sue D, Stringer W, Sietsema K, Sun X, et al. Chapter 4; Measurements during integrative cardiopulmonary exercise testing. Principles of Exercise testing and interpretation; 5th edition. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2012. p. 91-94.

(19) Myers J, Arena R, Cahalin LP, Labate V, Guazzi M. Cardiopulmonary Exercise Testing in Heart Failure. Curr Probl Cardiol 2015 8;40(8):322-372.

(20) Belardinelli R, Lacalaprice F, Carle F, Minnucci A, Cianci G, Perna GP, et al. Exercise-induced myocardial ischaemia detected by cardiopulmonary exercise testing. Eur Heart J 2003;24(14):1304-1313.

(21) Sun X, Hansen JE, Oudiz RJ, Wasserman K. Gas Exchange Detection of Exercise-Induced Right-to-Left Shunt in Patients With Primary Pulmonary Hypertension. Circulation 2002 January 01;105(1):54-60.

(22) Folinsbee LJ, Wallace ES, Bedi JF, Horvath SM. Exercise respiratory pattern in elite cyclists and sedentary subjects. Med Sci Sports Exerc 1983;15(6):503-509.

(23) Peterson LR, Schechtman KB, Ewald GA, Geltman EM, De Las Fuentes L, Meyer T, et al. Timing of cardiac transplantation in patients with heart failure receiving ß-adrenergic blockers. Journal of Heart and Lung Transplantation 2003;22(10):1141-1148.

(24) Mancini DM, Eisen H, Kussmaul W, Mull R, Edmonds Jr. LH, Wilson JR. Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure. Circulation 1991;83(3):778-786.

(25) Mehra MR, Kobashigawa J, Starling R, Russell S, Uber PA, Parameshwar J, et al. Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006. Journal of Heart and Lung Transplantation 2006;25(9):1024-1042.

21

(26) Gitt AK, Wasserman K, Kilkowski C, Kleemann T, Kilkowski A, Bangert M, et al. Exercise anaerobic threshold and ventilatory efficiency identify heart failure patients for high risk of early death. Circulation 2002;106(24):3079-3084.

(27) Beckles MA, Spiro SG, Colice GL, Rudd RM. The physiologic evaluation of patients with lung cancer being considered for resectional surgery. Chest 2003;123(1 SUPPL.):105S-114S.

(28) Voduc N. Physiology and clinical applications of cardiopulmonary exercise testing in lung cancer surgery. Thoracic Surgery Clinics 2013;23(2):233-245.

(29) Older P, Hall A, Hader R. Cardiopulmonary exercise testing as a screening test for perioperative management of major surgery in the elderly. Chest 1999;116(2):355-362.

(30) Wilson RJT, Davies S, Yates D, Redman J, Stone M. Impaired functional capacity is associated with all-cause mortality after major elective intra-abdominal surgery. Br J Anaesth 2010;105(3):297-303.

(31) Goodyear S, Yow H, Saedon M, Shakespeare J, Hill C, Watson D, et al. Risk stratification by pre-operative cardiopulmonary exercise testing improves outcomes following elective abdominal aortic aneurysm surgery: a cohort study. Perioperative Medicine 2013;2(1):10.

(32) Nagamatsu Y, Shima I, Yamana H, Fujita H, Shirouzu K, Ishitake T. Preoperative evaluation of cardiopulmonary reserve with the use of expired gas analysis during exercise testing in patients with squamous cell carcinoma of the thoracic esophagus. J Thorac Cardiovasc Surg 2001 6;121(6):1064-1068.

(33) Pina HL, Balady GJ, Hanson P, Labovitz AJ, Madonna DW, Myers J. Guidelines for clinical exercise testing laboratories: A statement for healthcare professionals from the committee on exercise and cardiac rehabilitation, American Heart Association. Circulation 1995;91(3):912-921.

(34) Myers J, Arena R, Franklin B, Pina I, Kraus WE, McInnis K, et al. Recommendations for clinical exercise laboratories: A scientific statement from the american heart association. Circulation 2009;119(24):3144-3161.

(35) Rodgers GP, Ayanian JZ, Balady G, Beasley JW, Brown KA, Gervino EV, et al. American College of Cardiology/American Heart Association Clinical Competence Statement on Stress Testing: A report of the American College of Cardiology/American Heart Association/American College of Physicians - American Society of Internal Medicine Task Force on Clinical Competence. J Am Coll Cardiol 2000;36(4):1441-1453.

(36) Colquhoun D, Freedman B, Cross D, Fitzgerald B, Forge B, Hare DL, et al. Clinical Exercise Stress Testing in Adults (2014). Heart, Lung and Circulation (0).

Healthcare professional’s guide to Cardio-Pulmonary ... · Dr Sathish Kumar Parasuraman, MRCP...

Documents

Transcript of Healthcare professional’s guide to Cardio-Pulmonary ... · Dr Sathish Kumar Parasuraman, MRCP...